healthcare

Article
Measuring Transformational Leadership in
Establishing Nursing Care Excellence
Sarah E. Moon 1, *, Pieter J. Van Dam 2 and Alex Kitsos 3
1 Australian Institute of Health Service Management, University of Tasmania, Hobart, TAS 7005, Australia
2 School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7005, Australia;
pieter.vandam@utas.edu.au
3 Wicking Dementia Research & Education Centre, University of Tasmania, Hobart, TAS 7005, Australia;
alex.kitsos@utas.edu.au
* Correspondence: moone@utas.edu.au




Received: 21 October 2019; Accepted: 1 November 2019; Published: 4 November 2019


Abstract: Transformational leadership (TL) is known to be essential to achieving Magnet® recognition,

an internationally prestigious status for nursing care excellence. Since its inception in the 1980s,
empirical studies have identified benefits of implementing the Magnet® Model involving improved
patient care and nursing workforce outcomes. However, little is known about the leadership styles of
nurse managers (NMs) working in a regional Australian context, which may hinder achieving Magnet®
status. To close the knowledge gap, a self-administered survey was conducted to measure leadership
styles of NMs at a large health organization comprising hospitals with a wide range of service profiles
in regional Australia using a validated tool—the Multifactor Leadership Questionnaire (MLQ-6S).
One-way of variance (ANOVA) was used to identify statistical significance between respondents’
demographic characteristics (e.g., age, education, gender) and their MLQ-6S scores. Respondents
(n = 78) reported their leadership styles as more transformational, compared to transactional or
passive/avoidant leadership styles. The findings indicated that NMs’ higher education (p = 0.02)
and older age (p = 0.03) were associated with TL styles, whereas passive/avoidant leadership was
generally reported by female (p = 0.04) and younger (p = 0.06) respondents. This study has identified
differences in reported leadership styles among NMs, providing a unique organizational insight into
developing strategies to improve NMs’ TL, which could help to facilitate the implementation of the
Magnet® framework. Healthcare organizations in similar settings could benefit from replicating this
study to identify a dominant leadership style and customize strategies to improve TL.

Keywords: transformational leadership; Magnet; Multifactor Leadership Questionnaire; nursing

workforce; evidence based; healthcare management; leadership development

1. Introduction
Transformational Leadership (TL) has been identified as one of the most effective leadership styles
in health services [1,2]. In TL, a leader mobilizes followers’ motivations toward an organizational
vision by: empowering staff; challenging them beyond the status quo; and recognizing their individual
needs and inspirations [3,4]. This approach has resulted in positive organizational performance, such
as improved nurse retention and care outcomes [5–12]. The impact of TL is recognized by the American
Nurses Credentialing Center (ANCC) through the Magnet Recognition Program® (Magnet® ) [13],
which was developed in the 1980s upon empirical evidence to enable superior nurse recruitment
and retention in efforts to combat a national nurse shortage [14,15]. TL is the first component of the
Magnet® framework and overarches the other four elements: Structural Empowerment, Exemplary
Professional Practice, New Knowledge, Innovations & Improvements, and Empirical Outcomes

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Healthcare 2019, 7, x 2 of 11
Healthcare 2019, 7, 132 2 of 11

Empowerment, Exemplary Professional Practice, New Knowledge, Innovations & Improvements,

and Empirical
(Figure Outcomes
1). To obtain Magnet ® recognition,
(Figure 1). To obtain Magnet® recognition,
a healthcare a healthcare
facility is required facility is required
to demonstrate nursing
to demonstrate
excellence nursing
aligned excellence
with the aligned
framework, with theby
evidenced framework, evidencedofby
empirical outcomes empirical
nursing staffoutcomes of
and patient
nursing staff and patient care
care at the organization [13]. at the organization [13].

Figure 1. The Magnet® framework.

Figure 1. The Magnet® framework.
Recognizing the benefits of Magnet® , a healthcare service organization in regional Australia
(hereafter the Studied
Recognizing the Organization) has embarked
benefits of Magnet®, on a journey
a healthcare to the
service Magnet® designation.
organization However,
in regional Australia
there has been little research examining TL among nurses and midwives in regional
(hereafter the Studied Organization) has embarked on a journey to the Magnet® designation. Australia, which
could provide guidance and support successful Magnet ® implementation. Previous Australian
However, there has been little research examining TL among nurses and midwives in regional
studies [16–18] ® —related surveys to metropolitan settings. Survey instruments
Australia, whichconducted Magnet
could provide guidance and support successful Magnet® implementation. Previous
used in these studies involved leadership aspects, but lacked
Australian studies [16–18] conducted Magnet®—related a focus
surveys to on TL, which is
metropolitan the leadership
settings. Survey
style required to achieve ®
instruments used in theseMagnet recognition.
studies involved To close
leadership the knowledge
aspects, but lackedgap, a survey
a focus was
on TL, conducted
which is the
to measure leadership styles of the Studied Organization’s NMs.
leadership style required to achieve Magnet® recognition. To close the knowledge gap, a survey was
conducted to measure leadership styles of the Studied Organization’s NMs.
1.1. Transformational Leadership
1.1. Transformational
TL was originally Leadership
conceptualized in the 1970s by Burns [19] who juxtaposed TL with a comparable
leadership style, known as transactionalinleadership
TL was originally conceptualized the 1970s(TAL). Burns
by Burns defined
[19] who TL as a relationship
juxtaposed TL with in a
which “leaders and followers raise one another to higher levels of motivation
comparable leadership style, known as transactional leadership (TAL). Burns defined TL as a and morality” [19]
(p. 6). Conversely,
relationship TAL“leaders
in which is defined as followers
and a relationship,
raise motivated
one another by to
self-interest rather
higher levels of than a collective
motivation and
good, where a leader exchanges a reward or reinforcement with task accomplishment
morality” [19] (pp. 6). Conversely, TAL is defined as a relationship, motivated by self-interest or failure,
rather
respectively
than [19].good,
a collective Later, TL was
where expanded
a leader and refined
exchanges a reward byorBass and Avoliowith
reinforcement [20]task
intoaccomplishment
four distinctive
or failure, respectively [19]. Later, TL was expanded and refined by Bass and AvolioIndividualized
subthemes: Idealized Influence, Inspirational Motivation, Intellectual Stimulation, and [20] into four
Consideration.
distinctive A transformational
subthemes: leader builds
Idealized Influence, trust andMotivation,
Inspirational acts with integrity (Idealized
Intellectual Influence);
Stimulation, and
creates a shared vision and motivates others toward it (Inspirational Motivation);
Individualized Consideration. A transformational leader builds trust and acts with integrity looks for new ideas
and beyondInfluence);
(Idealized the status quo (Intellectual
creates a sharedStimulation);
vision and and treats and
motivates values
others others it
toward as (Inspirational
an individual
Motivation); looks for new ideas and beyond the status quo (Intellectual Stimulation); andAvolio
(Individualized Consideration). In addition, expanding from TL and TAL, Bass and [20]
treats and
incorporated
values others another dimension,
as an individual called passive/avoidant
(Individualized Consideration).leadership styles,expanding
In addition, in which froma leaderTL fails
and
to action until task failure (Management-B-y-Exception) and is absent from employee-related
TAL, Bass and Avolio [20] incorporated another dimension, called passive/avoidant leadership styles, issues
(Laissez-Faire).
in which a leader Together,
fails to the elements
action comprise
until task the(Management-B-y-Exception)
failure Full Range Leadership [4] (Table and 1).is absent from
employee-related issues (Laissez-Faire). Together, the elements comprise the Full Range Leadership
[4] (Table 1).
Healthcare 2019, 7, 132 3 of 11

Table 1. Elements of Full Range Leadership [4].

Full Range Leadership Element

Idealized Influence
Inspirational Motivation
Transformational leadership
Intellectual Stimulation
Individualized Consideration
Contingent Rewards
Transactional leadership
Active Management-By-Exception
Passive Management-By-Exception
Passive/avoidant leadership
Laissez-Faire

Organizational outcomes from TL style have been widely researched and reported across a variety
of disciplines [4]. In a nursing context, a systematic review reported that leadership styles which
concentrate on people and relationships, such as TL, were associated with superior job satisfaction
compared to those task-based styles, including TAL [21]. Demonstrated organizational benefits from
TL include better practice environment [7,8,22,23] and superior nurse retention [12,24–26].

1.2. Transformational Leadership in Magnet®

TL establishes a leadership approach to cultivate an environment in which nurse leaders create
a vision and support other nurses to lead change [13]. The current Magnet® framework requires
the highest responsible nursing officer of an organization to demonstrate TL by fulfilling relevant
requirements to qualify as a Magnet® facility [27]. Recent studies have demonstrated that TL styles
among nurse managers (NMs) play a key role in developing and sustaining a Magnet® culture [7,28].
Similarly, the role of NMs employed at various levels in creating a positive workplace culture has been
consistently highlighted in the Australian literature [29–32]. Therefore, the imperative of TL can be
extended to not only the most senior nursing officer, but also all nurses whose leadership capability
impacts on shaping and sustaining Magnet® culture, particularly middle and senior managers.

1.3. Magnet® in Regional Australia

Difficulties in recruiting and retaining nurses and midwives are more pronounced in regional
Australia [33]. The island state of Tasmania, where the Studied Organization is located, is classified as
regional and remote [34] with a population, approximately, of 530,000 [35], with a heightened healthcare
demand according to the latest report [36]. Healthcare organizations in the state are increasingly
experiencing difficulties in maintaining a sustainable supply of nurses [37]. The Studied Organization
is one of few Australian regional health organizations to have officially announced its intention to apply
for Magnet® designation. Therefore, local knowledge of leadership styles could assist the Studied
Organization to identify strengths and development needs to build a workplace environment that
supports Magnet® implementation.

1.4. Study Purpose

This study aimed to measure the leadership styles held by the NMs working in a healthcare
organization in regional Australia using a survey tool (MLQ-6S) and to compare the survey result
against the first element of the Magnet® framework—Transformational Leadership—in order to inform
suitable strategies for leadership development by identifying the unique contextual strengths and
improvement opportunities.

2. Materials and Methods

A survey was used to measure prevalent leadership styles among a cohort of NMs. The
Multifactor Leadership Questionnaire Form 6S (MLQ-6S) [38], as dependent variables, and additional
Healthcare 2019, 7, 132 4 of 11

demographic questions developed by the authors, as independent variables, comprised the study’s
survey questionnaire. The MLQ was developed by Bass and Avolio based on research across multiple
disciplines, in which its validity and reliability was demonstrated [4,39–42]. Twenty-one items are
included in MLQ-6S to measure three different leadership styles—TL, TAL (Contingent Reward)
and passive/avoidant leadership (Passive Management-By-Exception, Laissez-Faire)—under seven
dimensions. Each item measures one of the three leadership styles, using a 5-point Likert scale (0 = Not
at all through to 4 = Frequently, if not always). The scores from the three items, under the seven
subthemes, are then combined to be categorized in High (9–12), Moderate (5–8) and Low (1–4) [38].
Cronbach’s alpha performed for the 21 items of the MLQ-6S were 0.78, indicating acceptable reliability.
In addition, seven demographic questions, such as age, gender and education level, were added to
the MLQ-6S.
A convenience sampling identified 183 suitable NMs from the studies organization, ranging from
community to acute hospitals. A list of the 183 invitees were obtained from staff directory that was
available publicly. Those who were acting in a management role or were employed on a temporary or
short-term basis were excluded from the sample. Situated in a hierarchical structure of the organization,
this group included middle and senior nurse managers, whose roles incorporated responsibilities and
accountabilities for managing and leading nurses and midwives in a unit/ward, a service stream or the
organization toward optimized care outcomes.
The survey was self-administered on an anonymous and voluntary basis via an online survey
website, LimeSurvey [43]. The identified NMMs were invited via an email which included survey
information and a link to the survey website, providing study information and a consent button. Three
weekly follow-up reminders in total were emailed until the survey was closed. Collected over four
weeks in January and February 2018, all responses were de-identified, with results aggregated, to avoid
potential re-identification by chance.
All data manipulation and analysis was completed in the statistical computer program, R [44].
One-way ANOVA was used to compare mean MLQ-6S scores between demographic groups (i.e.,
genders, age-groups, education levels, etc.) and to identify statistically significant differences between
the means of two or more independent groups. Results were considered significant when p < 0.05,
which reflects an association that has unlikely occurred due to chance or error.
This study was approved by the Tasmanian Health and Medical Human Research Ethics Committee
(H0016980).

3. Results
A total of seventy-eight participants (n = 78) completed the survey with a 42.6% response rate.
Incomplete responses were excluded from this study. Sixty-seven (86%) of the respondents were
female. The largest age group was 56–60 years (n = 21, 27%), with 46% of the participants over 51 years
of age. Mid-level nurse managers comprised 73% (n = 57) of the respondents. The majority of the NMs
(n = 61, 78%) had completed post-graduate qualifications (Table 2).
The MLQ scores by the participants indicated that the NMs at the studied organization evaluated
their leadership styles more towards TL. Out of the score 12, which is the highest level of the
corresponding leadership style, the NMMs scored, on average: 9.0 (High) in TL; 7.2 (Moderate) in
TAL; and 6.3 (Moderate) in passive/avoidant leadership. For the TL elements in particular, scores in
Individualized Consideration (9.5) and Idealized Influence (9.2) were higher than those in Inspirational
Motivation (8.6) and Intellectual Stimulation (8.6).
Healthcare 2019, 7, 132 5 of 11

Table 2. Demographic responses of survey participants.

Category Description No. of Responses (%)

Total 78 (100)
Female 67 (86)
Gender Male 11 (14)
Other 0
31–35 years 4 (5)
36–40 years 7 (9)
41–45 years 6 (7)
Age 46–50 years 15 (19)
51–55 years 17 (22)
56–60 years 21 (27)
61 or older 8 (10)
North 27 (35)
Region North West 19 (24)
South 32 (41)
Nurse Manager with no clinical responsibilities 10 (13)
Nurse (Unit) Manager 47 (60)
Role
Assistant Director of Nursing 12 (15)
(Co-) Director or Executive Director of Nursing 9 (12)
Hospital/training Certificate 6 (8)
Bachelor’s Degree 11 (14)
Post-graduate Certificate 12 (15)
Highest education
Post-graduate Diploma 22 (28)
Master’s Degree 27 (35)
Doctoral Degree 0 (0)
Less than 1 year 1 (1)
1–5 years 7 (9)
Work length at current 6–10 years 12 (15)
hospital 11–15 years 8 (10)
16–20 years 8 (10)
21 years plus 42 (54)
Community/Primary care 4 (5)
Hospital/Acute care 66 (85)
Work setting
Non-hospital inpatient facility (sub-acute care) 3 (4)
Other 5 (6)

Significant associations were seen between NMs’ education, age and gender, and their reported
leadership styles. A strong association (p = 0.02) was found between NMs’ education and differences
in the Intellectual Stimulation scores, which overall increased with a higher qualification. NMs’ age
revealed statistically significant differences in Individualized Consideration (p = 0.03), in which scores
gradually increased until the peak at age 51–55 years before reducing slightly thereafter. A weaker
association (p = 0.06) was found between age and Management-By-Exception (Passive) where the
score peaked at the youngest group, aged 31–35 years. Female respondents reported higher level of
Management-By-Exception (Passive) with statistical significance (p = 0.04). Other variables, including
work roles, regions, the length of employment, and the work setting, did not yield statistical significance
in associations with MLQ scores (Table 3).
Healthcare 2019, 7, 132 6 of 11

Table 3. Analysis of MLQ-6S scores by respondent demographics.

MLQ Factors (MLQ-6S) Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Factor 7
Leadership styles Transformational Transactional Passive/Avoidant
MLQ-6S score average 9.2 8.6 8.7 9.5 7.2 8.4 4.1
Average score for leadership style 9.0 7.2 6.3
Idealized Inspirational Intellectual Individualized Contingent Management-By-
Laissez Faire
Demographic variance Influence Motivation Stimulation Consideration Reward Exception
(mean (SD))
(mean (SD 1 )) (mean (SD)) (mean (SD)) (mean (SD)) (mean (SD)) (mean (SD))
Gender Female 9.2 (1.4) 8.6 (1.5) 8.6 (1.7) 9.5 (1.5) 7.2 (2.3) 8.6 (1.5) 4.3 (2.1)
Male 9.1 (1.6) 8.8 (1.1) 8.7 (1.4) 9.1 (1.3) 7.0 (2.0) 7.5 (2.1) 3.2 (1.8)
p-value 2 0.79 0.66 0.88 0.37 0.74 0.04 0.07
Age 31–35 9.5 (0.6) 8.8 (1.3) 9.3 (2.5) 8.5 (1.3) 5.8 (1.3) 9.3 (1.7) 4.5 (2.1)
36–40 9.0 (1.5) 9.4 (1.0) 8.9 (1.6) 8.6 (1.5) 7.7 (2.0) 7.1 (0.9) 3.6 (2.2)
41–45 10.0 (1.4) 7.8 (1.6) 7.5 (0.8) 8.8 (1.5) 6.7 (2.1) 7.7 (1.0) 2.8 (2.4)
46–50 9.2 (1.5) 8.9 (1.4) 8.8 (1.7) 8.9 (1.2) 7.1 (2.6) 8.3 (1.2) 4.1 (1.8)
51–55 9.5 (1.5) 9.1 (1.4) 9.2 (1.4) 10.2 (1.7) 7.9 (2.3) 8.4 (2.2) 4.2 (2.3)
56–60 8.8 (1.3) 8.2 (1.5) 8.4 (1.7) 9.8 (1.2) 7.1 (1.9) 9.1 (1.5) 4.8 (2.0)
≥ 61 9.0 (1.2) 8.0 (1.1) 8.1 (2.2) 9.8 (1.2) 7.0 (2.8) 7.9 (1.6) 3.6 (1.6)
p-value 0.48 0.13 0.34 0.03 0.66 0.06 0.46
Highest completed Education Hospital training 8.8 (1.2) 7.2 (1.3) 8.0 (1.4) 9.2 (1.2) 7.2 (1.8) 9.3 (1.6) 4.7 (0.8)
Bachelor’s 9.1 (1.0) 8.9 (0.9) 8.6 (1.2) 9.0 (1.5) 7.3 (2.3) 8.2 (1.0) 4.6 (1.5)
Post-grad Certificate 9.0 (1.3) 8.4 (1.2) 7.4 (1.4) 9.5 (1.3) 6.6 (2.4) 8.3 (1.5) 4.3 (1.6)
Post-grad Diploma 9.6 (1.4) 8.5 (1.6) 8.7 (1.6) 9.7 (1.6) 7.4 (2.4) 8.6 (1.7) 4.3 (2.4)
Master’s 9.1 (1.6) 8.9 (1.5) 9.3 (1.7) 9.5 (1.5) 7.3 (2.2) 8.2 (1.9) 3.6 (2.3)
Doctoral 0 0 0 0 0 0 0
p-value 0.70 0.08 0.02 0.73 0.89 0.51 0.62
1 SD: standard deviation; 2 p-value is significant at 0.05.
Healthcare 2019, 7, 132 7 of 11

4. Discussion
Survey findings indicated that (1) TL was the major leadership styles (TL: 9.0; TAL: 7.2;
Passive/avoidant: 6.3) among the NMs of the studied organization; however, (2) the frequency
of TL being practiced (‘3 = Sometimes’) could be improved. The high score in TL can be interpreted as a
positive result, based on the current evidence that TL has been linked to improved outcomes in nursing
workforce and service delivery outcomes in healthcare organizations [7,8,12,21–26]. This finding also
supports the studied organization’s journey to Magnet® as its measured dominant leadership style
aligns with TL. the highest score obtained in Idealized Influence (9.2) is noteworthy as Bass and Avolio [4]
highlights it as the most potent element in TL.
However, a caution needs to be applied in that self-identification by the NMs may not necessarily
means that these behaviors are displayed. The enactment of leadership is influenced by the context
in which leadership is practiced [45]. A work environment might contain barriers to enact TL in
day-to-day operations, such as a lack of support from management and clinical staff, lack of authority,
and lack of leadership skill development and education [46]. From a Magnet® perspective, a supportive
work environment is an important enabler for TL to flourish [47]. For instance, a display of trust and
acting with integrity, which are known qualities of Idealized Influence, are strong enablers of creating a
positive work environment in which Magnet® can be founded upon [48].
In assistance with the improvement in TL at the studied organization, the locally gained
knowledge could be considered in strategizing contextual TL development initiatives. These should
be suitable for NMs at the studied organization and the initiatives should be accompanied by
organization-wide support.

4.1. Intellectual Stimulation

The positive relationship between higher education and Intellectual Stimulation with strong
statistical significance (p = 0.02) indicates that academic education may improve NMs’ ability to
practice stronger TL [49]. Recognizing the importance of education, Magnet® requires that all
nurse managers possess a university-level nursing degree and that the highest responsible nursing
officer holds at least a master-level qualification [50]. However, the survey findings have indicated
an 8% gap in the bachelor’s-degree requirement and a potential cohort (14% holding bachelor’s
degree) for a post-graduate qualification uptake. Therefore, the studied organization may benefit
from nursing staff undertaking further academic qualifications through a partnership with a local
University [51]. To encourage the undertaking, organizational incentive programs, such as career
advancement opportunities upon qualification, may be used for current and/or prospect NMs.

4.2. Individualized Consideration

This survey has revealed progressed ageing of the NMs at the studied organization, with 46% of
the respondents being aged 51 years or older. This is consistent with the recent nursing workforce
sustainability data among Australian hospitals [52] which reported that Tasmania had the biggest
group of older nurses and midwives in the nation. Older respondents, however, showed a statistically
stronger (p = 0.03) association with an increased level of Individualized Consideration, while the youngest
group scored the highest in Management-By-Exception (Passive) with a weaker significance (p = 0.06).
Passive/avoidant leadership styles, including Management-By-Exception (Passive), have been linked to
negative impacts on nursing workforce [7,53]. Combining the two findings, it can be argued that older
NMs at the studied organization may possess more qualities of TL than their younger counterparts,
which is consistent with other studies that have linked older age to a higher level of TL [49,54]. From a
workforce sustainability standpoint, the progressed ageing of the nurse managers NMs at the studied
organization could be capitalized by potentially using these nurses and midwifes as mentors or
coaches. Individualized Consideration has been positively associated with change implementation in
healthcare organizations through relational and individualized measures, such as mentoring and
Healthcare 2019, 7, 132 8 of 11

coaching [55–57]. Thus, the identified strengths in Individualized Consideration in older NMs of the
studied organization could be expanded and transferred to other generations, particularly the young,
by developing and using a formal mentoring and coaching program. Accordingly, this may assist
Magnet® implementation at the studied organization.

4.3. Management-By-Exception
Interestingly, the statistically significant (p = 0.04) association between the participants’ gender and
Management-By-Exception (Passive) obtained in this survey appears to contradict current literature in
gender and leadership. In this study, the female NMs reported higher level of Management-By-Exception
(Passive). However, previous studies [58,59] confirmed that female groups tend to show TL styles
more often. The discrepancy may perhaps be attributed to the over-representation of female gender
(86%) in a small sample (n = 78) in this study. Further investigation would be required to determine
the validity of the gender difference in TL among the NMs at the Studied Organization.

4.4. Limitations and Future Research

Although inherent limitations exist due to the nature of a quantitative research design used in this
study, this study has contributed to advancing nursing leadership development, particularly from a
Magnet® perspective. The quantitative method limited opportunities to unveil details beyond the
survey items. The details may have led to specific and unique factors to optimize TL at the studied
organization and potentially in the regional Australian contexts. The self-report approach may have
induced over—or underestimation in leadership styles. In addition, the small sample (n = 78) may
have limited the generalizability of the results in a broader regional Australian context. Lastly, with
regard to the imbalance in the sample size between male and female participants addressed above,
a more balanced sex proportion may improve the representation of potential differences in leadership
behaviors affected by a person’s sex. On the other hand, this study has provided a foundation for the
nursing leadership evaluation within the context of regional healthcare organization in Australia in the
context of Magnet® recognition. Further replication and/or regular evaluations may be useful to help
inform leadership development aligned to Magnet® recognition at the healthcare organizations in
similar contexts. Additionally, local impacts of TL on nursing and care outcomes within the Studied
Organization could be explored to further promote TL development.

5. Conclusions
This study identified potential enablers of TL development towards Magnet® recognition
in a regional Australian context. The findings indicated specific TL components (Individualized
Consideration and Intellectual Stimulation) which could be improved by leveraging the maturity of
current and/or prospect NMs and advancing their academic education, respectively. Current evidence,
as discussed above, supports optimized TL assists healthcare organizations with achieving better care
outcomes, celebrated by obtaining Magnet® designation, and retaining the sustainability of nursing
and midwifery workforce. This study provides decision-makers of regional healthcare organizations
with a unique insight to help determine priorities toward TL development and achieve improved
organization outcomes.

Author Contributions: Conceptualization, S.E.M. and P.J.V.D.; data curation, S.E.M., P.J.V.D. and A.K.; formal
analysis, A.K.; investigation, S.E.M. and P.J.V.D.; methodology, S.E.M. and P.J.V.D.; project administration, S.E.M.
and P.J.V.D.; software, S.E.M. and A.K.; supervision, P.J.V.D.; visualization, S.E.M.; writing—original draft
preparation, S.E.M.; writing—review and editing, S.E.M., P.J.V.D. and A.K.
Funding: This research received no external funding.
Acknowledgments: Greg Peterson and Sarah Prior of the University of Tasmania proof-read this manuscript.
Conflicts of Interest: The authors declare no conflict of interest.
Healthcare 2019, 7, 132 9 of 11

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